Suggested objective performance goals and clinical trial design for evaluating catheter-based treatment of critical limb ischemia

The Management of Aneurysmal Degeneration of Lower Extremity Cryopreserved Saphenous Vein Bypass Grafts

BACKGROUND

The use of cryopreserved saphenous veins (CSVs) for the treatment of lower extremity peripheral arterial disease is an attractive option when there is no available autogenous vein. Prior studies found CSVs are at risk for aneurysmal degeneration requiring reoperation. As the management of these complications and patient outcomes is not well described, the objective of this case series is to describe the open and endovascular management of degenerative CSVs at a tertiary community center.

METHODS

All CSVs implanted for lower extremity bypass at our institution between 2001 and 2021 were retrospectively reviewed. All CSVs with evidence of aneurysmal change were included in this study. CSVs with evidence of active infection were excluded. The decision to intervene was left to the discretion of the operating surgeon. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded. Study end points included limb salvage and continued patency. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded.

RESULTS

Seventeen bypasses were identified to have aneurysmal degeneration in 13 patients in the absence of infection between 2001 and 2021. Nine of the 13 patients were male, and the average age and body mass index during the index procedure were 72 and 28, respectively. Indications for the index bypass included acute limb ischemia (9), popliteal aneurysm (2), and chronic limb threatening ischemia with Rutherford's class IV (5) and V (1). The mean time between the index procedure and first graft revision due to aneurysmal changes was 4 years. Most of the aneurysms did not occur at the site of anastomosis with 13 occurring in the body of the graft. Thirteen grafts were managed with open surgery and 3 were managed with endovascular techniques. All endovascular repairs were managed via covered stenting. Patients were followed for an average duration of 7 years from the initial bypass and 2 years from their last aneurysmal repair. Limb salvage in this cohort was 87% with 2 limbs requiring amputation, all of whom underwent open reconstruction. The mortality rate in this series was 54% and no patients died due to complications from their graft. Continued patency on Kaplan Meier survival curve analysis was 79% at 6 months, 65% at 1 year, 54% at 3 years, and 27% at 5 years.

CONCLUSIONS

In our experience, aneurysmal degeneration of CSV grafts was mostly managed with standard open surgical techniques, although endovascular therapy also proved acceptable. Limb salvage rates and continued patency of repair at 1 year in this cohort were acceptable. This case series highlights the importance of diligent surveillance for patients with CSVs.

Learning curve in tibial and pedal bypass with autologous vein graft

OBJECTIVES

The 2019 Global Vascular Guidelines recommended open bypass for patients at average risk with greater limb severity and anatomical complexity. However, the outcomes of tibial and pedal bypass (TPB) are inferior to those of above-the-knee surgical revascularization. This may be due to the technical difficulty and need for development of skills to perform TPB. However, there is a limited knowledge on the learning curve in TPB. Thus, the aim of the study is to assess this learning curve in a single-center retrospective analysis.

METHODS

Cases treated with TPB with an autologous vein conduit in patients with chronic limb-threatening ischemia (CLTI) at a Japanese single center from 2009 to 2022 were analyzed retrospectively. The primary endpoint was the learning curve for TPB.

RESULTS

The study included 449 TPB procedures conducted by a single main surgeon in patients with CLTI (median age, 75 years; 309 males; diabetes mellitus, 73%; end stage renal failure with hemodialysis, 44%). The operative time decreased significantly as the number of cases accumulated (p < .001). Using the cumulative sum (CUSUM) operative time, the learning curve was estimated to be phase 1 (initial learning curve) for 134 cases (1-134); phase 2 (competent period) for 179 cases (135-313); and phase 3 (mastery and challenging period) for 136 cases (314-449). The mean follow-up period was 34 ± 31 months. The 1- and 3-year limb salvage rates of 97% and 96% in phase 3 were significantly higher than those in phases 1 and 2 (p < .001, p = .029). Major adverse limb events (MALE) occurred in 117 (26%) patients, and the 1- and 3-year MALE rates of 10% and 17% in phase 3 were significantly lower than those in phases 1 and 2 (p < .001, p = .009).

CONCLUSIONS

In the study, vascular surgeon required a learning curve of 134 TPB cases to Overcoming the learning curve for bypass was associated with improvement of medium-term outcomes for limb salvage and freedom from MALE.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Anatomical and clinical factors associated with infrapopliteal arterial bypass outcomes in patients with chronic limb-threatening ischemia

The aim of this study was to identify anatomical and clinical factors associated with limb-based patency (LBP) loss, major adverse limb events (MALEs), and poor amputation-free survival (AFS) after an infrapopliteal arterial bypass (IAB) surgery according to the Global Limb Anatomic Staging System. A retrospective analysis of patients undergoing IAB surgery between January 2010 and December 2021 at a single institution was performed. Two-year AFS, freedom from LBP loss, and freedom from MALEs were assessed using the Kaplan-Meier method. Anatomical and clinical predictors were assessed using multivariate analysis. The total number of risk factors was used to calculate risk scores for subsequent categorization into low-, moderate-, and high-risk groups. IABs were performed on 103 patients. The rates of two-year freedom from LBP loss, freedom from MALEs, and AFS were 71.3%, 76.1%, and 77.0%, respectively. The multivariate analysis showed that poor run-off beyond the ankle and a bypass vein caliber of < 3 mm were significantly associated with LBP loss and MALEs. Moreover, end-stage renal disease, non-ambulatory status, and a body mass index of < 18.5 were significantly associated with poor AFS. The rates of freedom from LBP loss and MALEs and the AFS rate were significantly lower in the high-risk group than in the other two groups (12-month low-risk rates: 92.2%, 94.8%, and 94.4%, respectively; 12-month moderate-risk rates: 58.6%, 84.6%, and 78.3%, respectively; 12-month high-risk rates: 11.1%, 17.6%, and 56.2%, respectively; p < 0.001, p < 0.001, and p < 0.001, respectively). IAB is associated with poor clinical outcomes in terms of LBP, MALEs, and AFS in high-risk patients. Risk stratification based on these predictors is useful for long-term prognosis.

Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program

OBJECTIVE

Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting.

METHODS

This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis).

RESULTS

Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot.

CONCLUSIONS

In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.

Secondary interventions following open vs endovascular revascularization for chronic limb threatening ischemia in the BEST-CLI trial

OBJECTIVES

Patients undergoing revascularization for chronic limb-threatening ischemia experience a high burden of target limb reinterventions. We analyzed data from the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) randomized trial comparing initial open bypass (OPEN) and endovascular (ENDO) treatment strategies, with a focus on reintervention-related study endpoints.

METHODS

In a planned secondary analysis, we examined the rates of major reintervention, any reintervention, and the composite of any reintervention, amputation, or death by intention-to-treat assignment in both trial cohorts (cohort 1 with suitable single-segment great saphenous vein [SSGSV], n = 1434; cohort 2 lacking suitable SSGSV, n = 396). We also compared the cumulative number of major and all index limb reinterventions over time. Comparisons between treatment arms within each cohort were made using univariable and multivariable Cox regression models.

RESULTS

In cohort 1, assignment to OPEN was associated with a significantly reduced hazard of a major limb reintervention (hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.28-0.49; P < .001), any reintervention (HR, 0.63; 95% CI, 0.53-0.75; P < .001), or any reintervention, amputation, or death (HR, 0.68; 95% CI, 0.60-0.78; P < .001). Findings were similar in cohort 2 for major reintervention (HR, 0.53; 95% CI, 0.33-0.84; P = .007) or any reintervention (HR, 0.71; 95% CI, 0.52-0.98; P = .04). In both cohorts, early (30-day) limb reinterventions were notably higher for patients assigned to ENDO as compared with OPEN (14.7% vs 4.5% of cohort 1 subjects; 16.6% vs 5.6% of cohort 2 subjects). The mean number of major (mean events per subject ratio [MR], 0.45; 95% CI, 0.34-0.58; P < .001) or any target limb reinterventions (MR, 0.67; 95% CI, 0.57-0.80; P < .001) per year was significantly less in the OPEN arm of cohort 1. The mean number of reinterventions per limb salvaged per year was lower in the OPEN arm of cohort 1 (MR, 0.45; 95% CI, 0.35-0.57; P < .001 and MR, 0.66; 95% CI, 0.55-0.79; P < .001 for major and all, respectively). The majority of index limb reinterventions occurred during the first year following randomization, but events continued to accumulate over the duration of follow-up in the trial.

CONCLUSIONS

Reintervention is common following revascularization for chronic limb-threatening ischemia. Among patients deemed suitable for either approach, initial treatment with open bypass, particularly in patients with available SSGSV conduit, is associated with a significantly lower number of major and minor target limb reinterventions.

Age-related white matter change disease predicts long-term cerebrovascular morbidity following carotid endarterectomy

PURPOSE

Cerebrovascular diseases remain a critical focus of medical research due to their substantial impact on global health. Carotid stenosis, often associated with atherosclerosis and advancing age, profoundly affects cerebral blood supply and white matter integrity. This study aims to assess how age-related white matter changes (ARWMC) score, applied to cortex and Basal Ganglia, relates to cardiovascular and cerebrovascular events in patients who underwent carotid endarterectomy (CEA).

METHODS

Ninety patients undergoing CEA with regional anesthesia were prospectively enrolled from January 2012 to January 2022, and a post hoc analysis of patients with preoperative cerebral CT scans were reviewed, stratified by ARWMC score. Survival analysis and multivariate Cox regression were employed to assess time-dependent variables and independent predictors.

RESULTS

A median follow-up of 51 months (Inter-quartile range [IQR [ [38.8-63.2] months) revealed higher ARWMC grades in the basal ganglia independently associated with significantly increased stroke risk (HR=5.070, 95% CI: 1.509-17.031, P=0.009), acute heart failure (HR=19.066, 95% CI: 2.038-178.375, P=0.01), major adverse cardiovascular events (MACE) (HR=2.760, 95% CI: 1.268-6.009, P=0.011), and all-cause mortality (HR=2.497, 95% CI:1.009-6.180, P=0.048). Polyvascular disease and chronic kidney disease emerged as additional predictors of MACE.

CONCLUSION

Higher grades of ARWMC score in the basal ganglia were related to a significant increase in the risk of adverse cardiovascular events, such as stroke, MACE, AHF and all-cause mortality. This study suggests that ARWMC may have potential as a possible predictor of long-term cardio- and cerebrovascular events in patients undergoing CEA.

Influence of a Novel Morphology-Driven Classification on Limb Salvage after Isolated Tibial Intervention for Chronic Limb Threatening Ischemia

BACKGROUND

Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI.

METHODS

A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated Infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300mm (1 point) and poor pedal runoff score (1 point). Patients were then divided into three groups: low-risk (0 or 1 points), moderate-risk (2 points), and high-risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-orientated outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated.

RESULTS

1607 patients (55% male, average age 60 years, 3846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic. origin Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day Major Amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate-risk and high-risk exceeded the goal threshold. For the OPG. Freedom from MALE was 60±5%, 46±5%, and 22±9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± SEM; p =0.008. Overall amputation-free survival (AFS) was 55±5%, 37±6%, and 18±7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± SEM; p=0.003).

CONCLUSIONS

Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI.

Percutaneous thrombectomy for acute limb ischemia is associated with equivalent limb and mortality outcomes compared with open thrombectomy

BACKGROUND

Acute limb ischemia (ALI) carries a 15% to 20% risk of combined death or amputation at 30 days and 50% to 60% at 1 year. Percutaneous mechanical thrombectomy (PT) is an emerging minimally invasive alternative to open thrombectomy (OT). However, ALI thrombectomy cases are omitted from most quality databases, limiting comparisons of limb and survival outcomes between PT and OT. Therefore, our aim was to compare in-hospital outcomes between PT and OT using the National Inpatient Sample.

METHODS

We analyzed survey-weighted National Inpatient Sample data (2015-2020) to include emergent admissions of aged adults (50+ years) with a primary diagnosis of lower extremity ALI undergoing index procedures within 2 days of hospitalization. We excluded hospitalizations with concurrent trauma or dissection diagnoses and index procedures using catheter-directed thrombolysis. Our primary outcome was composite in-hospital major amputation or death. Secondary outcomes included in-hospital major amputation, death, in-hospital reintervention (including angioplasty/stent, thrombolysis, PT, OT, or bypass), and extended length of stay (eLOS; defined as LOS >75th percentile). Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were generated by multivariable logistic regression, adjusting for demographics, frailty (Risk Analysis Index), secondary diagnoses including atrial fibrillation and peripheral artery disease, hospital characteristics, and index procedure data including the anatomic thrombectomy level and fasciotomy. A priori subgroup analyses were performed using interaction terms.

RESULTS

We included 23,795 survey-weighted ALI hospitalizations (mean age: 72.2 years, 50.4% female, 79.2% White, and 22.3% frail), with 7335 (30.8%) undergoing PT. Hospitalization characteristics for PT vs OT differed by atrial fibrillation (28.7% vs 36.5%, P < .0001), frequency of intervention at the femoropopliteal level (86.2% vs 88.8%, P = .009), and fasciotomy (4.8% vs 6.9%, P = .006). In total, 2530 (10.6%) underwent major amputation or died. Unadjusted (10.1% vs 10.9%, P = .43) and adjusted (aOR = 0.96 [95% CI, 0.77-1.20], P = .74) risk did not differ between the groups. PT was associated with increased odds of reintervention (aOR = 2.10 [95% CI, 1.72-2.56], P < .0001) when compared with OT, but this was not seen in the tibial subgroup (aOR = 1.31 [95% CI, 0.86-2.01], P = .21, Pinteraction < .0001). Further, 79.1% of PT hospitalizations undergoing reintervention were salvaged with endovascular therapy. Lastly, PT was associated with significantly decreased odds of eLOS (aOR = 0.80 [95% CI, 0.69-0.94], P = .005).

CONCLUSIONS

PT was associated with comparable in-hospital limb salvage and mortality rates compared with OT. Despite an increased risk of reintervention, most PT reinterventions avoided open surgery, and PT was associated with a decreased risk of eLOS. Thus, PT may be an appropriate alternative to OT in appropriately selected patients.

Polyvascular Disease Influences Long-Term Cardiovascular Morbidity in Carotid Endarterectomy

INTRODUCTION/OBJECTIVE

Carotid stenosis (CS) is an important cause of ischemic stroke. Secondary prevention lies in performing a carotid endarterectomy (CEA) procedure, the recommended treatment in most cases. When 2 or more vascular regions are simultaneously affected by atherosclerosis, mainly the carotid arteries, coronary arteries, or limb arteries, a multivessel disease polyvascular disease (PVD) is present. This study aims to assess the potential role of PVD as a long-term predictor of major adverse cardiovascular events (MACE) and all-cause mortality in patients submitted to CEA.

METHODS

From January 2012 to December 2021, patients submitted to CEA for carotid stenosis in a tertiary care and referral center were eligible from a prospective database. A posthoc survival analysis was performed using the Kaplan-Meier survival curve method. The primary outcome was the incidence of long-term MACE and all-cause mortality. Secondary outcomes included acute myocardial infarction (AMI), major adverse limb events (MALE), stroke, and acute heart failure (AHF).

RESULTS

A total of 207 patients were enrolled, with a median follow-up of 63 months. The mean age was 70.4 ± 8.9, and 163 (78.7%) were male. There were 65 (31.4%) patients that had 2 arterial vascular territories affected, and 29 (14.0%) patients had PVD in 3 arterial beds. On multivariable analysis, both MACE and all-cause mortality had as independent risk factors age (aHR 1.039, P = 0.003; aHR 1.041, P = 0.019), chronic kidney disease (aHR 2.524, P = 0.003; aHR 3.377, P < 0.001) and PVD2 (aHR 3.381, P < 0.001; aHR 2.665, P = 0.013). PVD1 was only associated with MACE as a statistically significant risk factor (aHR 2.531, 1.439-4.450, P < 0.001).

CONCLUSIONS

PVD in patients with cerebrovascular disease (CVD) was revealed to carry a 2-fold increased risk for all-cause mortality and MACE during long-term follow-up. PVD may be a simple yet valuable tool in predicting all-cause mortality, MACE, AMI, and MALE after CEA.

Pedal medial arterial calcification influences the outcomes of isolated infra-malleolar interventions for chronic limb-threatening ischemia

OBJECTIVE

Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions.

METHODS

A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated.

RESULTS

A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS.

CONCLUSIONS

Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI.

Quality of Life in Patients With Chronic Limb-Threatening Ischemia Treated With Revascularization

BACKGROUND

In the BEST-CLI trial (Best Endovascular Versus Best Surgical Therapy for Patients With Chronic Limb-Threatening Ischemia), a prespecified secondary objective was to assess the effects of revascularization strategy on health-related quality of life (HRQoL).

METHODS

Patients with chronic limb-threatening ischemia were randomized to surgical bypass (Bypass) or endovascular intervention (Endo) in 2 parallel trials. Cohort 1 included patients with single-segment great saphenous vein; cohort 2 included those lacking suitable single-segment great saphenous vein. HRQoL was assessed over the trial duration using Vascular Quality-of-Life (VascuQoL), European Quality-of-Life-5D (EQ-5D), the Short Form-12 (SF-12) Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), Utility Index Score (SF-6D R2), and numeric rating scales of pain. HRQoL was summarized by cohort and compared within and between groups using mixed-model linear regression.

RESULTS

A total of 1193 and 335 patients in cohorts 1 and 2 with a mean follow-up of 2.9 and 2.0 years, respectively, were analyzed. In cohort 1, HRQoL significantly improved from baseline to follow-up for both groups across all measures. For example, mean (SD) VascuQoL scores were 3.0 (1.3) and 3.0 (1.2) for Bypass and Endo at baseline and 4.7 (1.4) and 4.8 (1.5) over follow-up. There were significant group differences favoring Endo when assessed with VascuQoL (difference, -0.14 [95% CI, -0.25 to -0.02]; P=0.02), SF-12 MCS (difference, -1.03 [95% CI, -1.89 to -0.18]; P=0.02), SF-6D R2 (difference, -0.01 [95% CI, -0.02 to -0.001]; P=0.03), numeric rating scale pain at present (difference, 0.26 [95% CI, 0.03 to 0.49]; P=0.03), usual level during previous week (difference, 0.26 [95% CI, 0.04 to 0.48]; P=0.02), and worst level during previous week (difference, 0.29 [95% CI, 0.02 to 0.56]; P=0.04). There was no difference between treatment arms on the basis of EQ-5D (difference, -0.01 [95% CI, -0.03 to 0.004]; P=0.12) or SF-12 PCS (difference, -0.41 [95% CI, -1.2 to 0.37]; P=0.31). In cohort 2, HRQoL also significantly improved from baseline to the end of follow-up for both groups based on all measures, but there were no differences between Bypass and Endo on any measure.

CONCLUSIONS

Among patients with chronic limb-threatening ischemia deemed eligible for either Bypass or Endo, revascularization resulted in significant and clinically meaningful improvements in HRQoL. In patients with an available single-segment great saphenous vein for bypass, but not among those without one, Endo was statistically superior on some HRQoL measures; however, these differences were below the threshold of clinically meaningful difference.

Perioperative complications of minor and major reinterventions for peripheral arterial disease

INTRODUCTION

Patients with peripheral arterial disease (PAD) frequently require reinterventions after lower-extremity revascularization (LER) to maintain perfusion. Current Society for Vascular Surgery guidelines define reinterventions as major or minor based on the magnitude of the procedure. While prior studies have compared primary LER procedures of different magnitudes, similar studies for reinterventions have not been performed. The objective of this study is to compare perioperative outcomes associated with major and minor reinterventions.

METHODS

Patients undergoing LER for PAD at a tertiary care center from 2013 to 2017 were included. A retrospective review of electronic medical records was performed, and reinterventions were categorized as major or minor based on the procedure magnitude. Minor reinterventions included endovascular procedures and open revision with patch angioplasty, while major reinterventions were characterized by open surgical or endovascular LER with catheter-directed thrombolysis (CDT). Perioperative outcomes following LER were captured and compared for major and minor reinterventions. An additional subgroup analysis was performed comparing outcomes associated with major reinterventions stratified into open major surgical reinterventions and CDT.

RESULTS

This study included 713 patients over a mean follow-up of 2.5 years. A total of 291 patients underwent 696 ipsilateral reinterventions (range = 1-12 reinterventions). Most reinterventions were minor (72.1%, N = 502) and 27.9% (N = 194) were major. Patients receiving reinterventions had an average age of 67.2 ± 11.5 and most were white (73.5%) males (60.1%) initially treated for claudication (58.2%) and CLTI (41.8%). There was significantly higher post-operative bleeding (9.8% vs 3.4%, p = .001), arterial thrombosis (3.1% vs 1.0%, p = .047), and acute renal failure (6.2% vs 2.4%, p = .014) after major reinterventions than minor. Additionally, major reinterventions had significantly higher return to the OR (17.0% vs 11.3%, p = .046) and longer hospital stays (7.5 vs 4.3 days, p = <.0001). Overall, major reinterventions were associated with significantly increased perioperative morbidity (37.6% vs 19.7%, p ≤ .001) with no difference in perioperative mortality. In the subgroup analysis, open reinterventions resulted in significantly longer hospital stays (8.6 days vs 5.5 days, p ≤ .001) and more wound infections than CDT (11.0% vs 0%, p = .017). However, there was no other significant difference in morbidity or mortality following treatment with open surgical reinterventions or CDT.

CONCLUSIONS

In this study, major reinterventions after LER were associated with greater perioperative morbidity than minor reinterventions, with no difference in mortality. Major reinterventions performed via open surgery and CDT had similar morbidity and mortality.

Common Criticisms and Rebuttals of the Best Endovascular Versus Best Surgical Therapy in Patients with Chronic Limb-Threatening Ischemia (BEST-CLI) Trial

The Best Endovascular Versus Best Surgical Therapy in Patients With Chronic Limb-Threatening Ischemia trial was a landmark trial which provides high-quality data for the decision-making regarding the treatment of chronic-limb threatening ischemia. Overall, the trial suggests that in patients with adequate greater saphenous vein conduit, bypass surgery should be offered as a first line treatment given superior outcomes. In this article, we outline the common critiques of the trial, followed by responses to provide a deeper understanding of the strengths and limitations of this important trial.

"Evolution of Drug-Coated Devices for the Treatment of Chronic Limb Threatening Ischemia"

For patients with Chronic Limb Threatening Ischemia (CLTI), endovascular approaches to revascularization are often employed as a component of multimodality care aimed at limb preservation. However, patients with CLTI are also prone to treatment failure, particularly following balloon angioplasty alone. Drug-coated devices utilizing Paclitaxel were developed to decrease restenosis but have been primarily studied in patients presenting with claudication. In recent years, data have emerged which describe the efficacy of drug-coated devices in the treatment of patients with CLTI. Concurrently, there has been major controversy surrounding the use of drug-coated devices in peripheral arterial disease. A historical narrative of the development and use of drug-coated devices for peripheral arterial disease is presented, along with discussion of major trials. Evidence argues that paclitaxel-based therapies for peripheral arterial disease (PAD) do not increase mortality risk compared to nondrug-coated devices. In CLTI patients, paclitaxel-based balloons and stents provide superior patency and freedom reintervention compared to nondrug-coated devices when treating femoropopliteal disease. However, the use of Paclitaxel-based therapies for below-the-knee (BTK) interventions has not been shown to provide clinically meaningful outcomes compared to nondrug-based therapies. Newer generation antiproliferative agents (Sirolimus, Everolimus) and delivery systems (bioabsorbable scaffolds) hold promise for BTK interventions with early data suggesting decreased rates of major amputation or major adverse limb events.

In the Loop: Endovascular Pedal Arch Revascularization

Advanced endovascular techniques are increasingly being utilized to treat patients with peripheral arterial disease and chronic limb-threatening ischemia to improve lower extremity arterial perfusion. In diabetic patients, pedal arch patency has been associated with improved wound healing, limb salvage, and overall survival. Pedal-plantar loop revascularization is a technique that can restore arterial inflow between the dorsal and plantar arteries of the foot. This article will describe the inframallelolar arterial anatomy and focus on imaging, percutaneous endovascular techniques, and clinical study outcomes of pedal artery interventions.

Role of Hemodynamic Assessment and Limitations in Ankle-Brachial Pressure Index, Toe- Brachial Pressure Index to Predict Wound Healing After Revascularization

Chronic limb-threatening ischemia (CLTI) represents one of the most severe forms of peripheral arterial disease implying impaired wound healing and tissue loss at the same time posing a significant impact on the quality of life of patients and a serious economic burden on healthcare systems around the world. A major challenge in the management of patients with CLTI is the validity and role of non-invasive hemodynamic parameters in assessing their clinical status before and after revascularization. Traditionally, the diagnosis of CLTI is routinely based on clinical symptoms and confirmed by measurements of non-invasive limb hemodynamics including ankle-brachial pressure index (ABPI) and toe-brachial pressure index (TBPI). However, whether these indices alone can provide definitive treatment or be used as adjunctive tool along with the implementation of novel techniques to help guide revascularization for CLI patients still remains unclear.

Early Outcomes of Interwoven Nitinol Wire Stent Placement versus Endarterectomy for the Treatment of Atherosclerotic Disease of the Common Femoral Artery

PURPOSE

To compare the clinical outcomes of common femoral artery (CFA) atherosclerotic disease treated with either surgical endarterectomy or an interwoven nitinol wire stent system.

MATERIALS AND METHODS

A retrospective review was conducted of all patients with chronic, de novo atherosclerotic CFA disease treated with surgical endarterectomy (CFAE) or stent placement between July 2019 and March 2022. Outcome measures assessed up to 12 months after procedure included clinical improvement, primary restenosis, target vessel revascularization (TVR), major adverse limb events (MALEs), and all-cause mortality.

RESULTS

Thirty-nine stents were deployed in 33 patients, and 56 CFAEs were performed in 55 patients. No differences were noted in the rate of primary patency (95.5% vs 94.4%, P = .618), TVR (2.9% vs 1.8%, P = .777), MALE (5.1% vs 5.4%, P = .949), and all-cause mortality (14.1% vs 3.6%, P = .076) between the stent and CFAE groups up to 12 months after procedure. There was greater improvement in median clinical severity in the stent group than in the CFAE group (Rutherford score change of 3.0 vs 1.5, P = .013). The median length of stay was less for the stent group (3 vs 7 days, P = .002), and there was a lower likelihood of severe or disabling adverse events in the stent group (0 vs 9 cases, P = .010).

CONCLUSIONS

Patients treated with an interwoven nitinol wire stent had patency rates comparable to those treated with CFAE while having a lower incidence of severe adverse events and a shorter length of hospital stay than those who underwent CFAE.

Drug-Eluting Resorbable Scaffold versus Angioplasty for Infrapopliteal Artery Disease

BACKGROUND

Among patients with chronic limb-threatening ischemia (CLTI) and infrapopliteal artery disease, angioplasty has been associated with frequent reintervention and adverse limb outcomes from restenosis. The effect of the use of drug-eluting resorbable scaffolds on these outcomes remains unknown.

METHODS

In this multicenter, randomized, controlled trial, 261 patients with CLTI and infrapopliteal artery disease were randomly assigned in a 2:1 ratio to receive treatment with an everolimus-eluting resorbable scaffold or angioplasty. The primary efficacy end point was freedom from the following events at 1 year: amputation above the ankle of the target limb, occlusion of the target vessel, clinically driven revascularization of the target lesion, and binary restenosis of the target lesion. The primary safety end point was freedom from major adverse limb events at 6 months and from perioperative death.

RESULTS

The primary efficacy end point was observed (i.e., no events occurred) in 135 of 173 patients in the scaffold group and 48 of 88 patients in the angioplasty group (Kaplan-Meier estimate, 74% vs. 44%; absolute difference, 30 percentage points; 95% confidence interval [CI], 15 to 46; one-sided P<0.001 for superiority). The primary safety end point was observed in 165 of 170 patients in the scaffold group and 90 of 90 patients in the angioplasty group (absolute difference, -3 percentage points; 95% CI, -6 to 0; one-sided P<0.001 for noninferiority). Serious adverse events related to the index procedure occurred in 2% of the patients in the scaffold group and 3% of those in the angioplasty group.

CONCLUSIONS

Among patients with CLTI due to infrapopliteal artery disease, the use of an everolimus-eluting resorbable scaffold was superior to angioplasty with respect to the primary efficacy end point. (Funded by Abbott; LIFE-BTK ClinicalTrials.gov number, NCT04227899.).

Outcomes of Arterial Bypass With the Human Acellular Vessel for Chronic Limb-Threatening Ischemia Performed Under the FDA Expanded Access Program

OBJECTIVE

To report outcomes of the human acellular vessel (HAV) implanted for limb salvage through the Food and Drug Administration (FDA) Expanded Access Program for patients with chronic limb-threatening ischemia with no autologous conduit.

METHODS

The HAV is a bioengineered vascular conduit designed with human vascular smooth muscle cells. The product is under regulatory study. From April 2019 to November 2021, the HAV was implanted in 14 patients (12 men; mean age, 62±14 years) at 3 US centers. Each case was performed with a single-use investigational new drug Expanded Access Program issued by the FDA. Institutional review board approval was obtained; technical and clinical outcomes were analyzed.

RESULTS

A single 6-mm-diameter (40-cm-long) HAV was implanted in 9 patients; 5 patients required 2 HAVs sewn together as a composite. Technical success was 100%. Median follow-up was 12 (range, 1 to 41) months. Primary and secondary patency rates were 72% and 81% at 12 months; assisted primary patency was attained in 4 patients. Amputation-free survival was 93% at 6 months and 77% at 12 months. All patients with a patent HAV experienced clinical improvement with no HAV-related infections or adverse events. There were 4 deaths in the cohort, late mortality unrelated to the HAV.

CONCLUSION

The HAV is a safe and effective "off-the-shelf" biologic conduit. This experience from the FDA Expanded Access Program in this population with few alternative limb salvage options will help guide regulatory deliberations for patients with lower extremity ischemia and no autologous bypass conduit options.

Association between End-Stage Renal Disease and Major Adverse Limb Events after Peripheral Vascular Intervention

PURPOSE

To examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4-6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI).

MATERIALS AND METHODS

Two contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass).

RESULTS

After PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58-6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06-23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71-33.50; P = .008).

CONCLUSIONS

ESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4-6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.

Failure-to-Salvage After Femoropopliteal Bypass Surgery is Associated With Nonmodifiable Risk Factors

INTRODUCTION

Bypass graft failure and major amputation are among the worst complications after femoropopliteal bypass surgery. In this large multicenter analysis, we examined our incidence and risk factors for failure-to-salvage (FTS) following either bypass surgery or bypass graft failure.

METHODS

A regional multicenter database was retrospectively queried for all femoropopliteal bypass procedures performed between 2002 and 2021. Re-do bypasses were excluded. The primary outcome was FTS, defined as major ipsilateral limb amputation within 90 d following index bypass surgery or bypass graft failure. Bypass graft failure was defined as critical stenosis or occlusion of the bypass graft requiring reintervention. Graft rescue was defined as bypass graft failure without subsequent major ipsilateral limb amputation within 90 d. Multivariable logistic regression analysis was utilized to identify factors associated with bypass graft failure and FTS.

RESULTS

Over the study period, 1315 femoropopliteal bypass procedures were performed across five hospitals. There were 25 major amputations within 90 d of initial bypass. Bypass graft failure was diagnosed in an additional 503 (38.3%) patients. Mean time to graft failure was 619 d. On multivariable analysis, bypass for tissue loss (adjusted odds ratio [aOR] 1.38 [95% confidence interval (CI) 1.03-1.83], P = 0.03) was associated with graft failure. Of patients with graft failure, 33 had major amputation, leading to an overall FTS incidence of 4.4% (n = 58) over a mean follow-up period of 3.4 y. Patient demographics, medical comorbidities, and bypass conduits were similar between the FTS and graft rescue groups (n = NS each). The FTS group more frequently underwent bypass for tissue loss (51.7% versus 29.8%, P = 0.002), and an infrageniculate bypass target was more frequently utilized in FTS compared to graft rescue patients (81.0% versus 60.4%, P = 0.002). Anticoagulation (34.5% in FTS versus 37.7% in rescue) and dual antiplatelet therapy (15.5% versus 22.1%, respectively) were similar between groups (P = NS each). On multivariable analysis, factors associated with FTS included infrageniculate target (aOR 2.42 [95% CI 1.22-4.08], P = 0.01), black race (aOR 2.47 [95% CI 1.04-5.84], P = 0.04), and bypass for tissue loss (aOR 4.75 [95% CI 1.41-16.0], P = 0.01). Anticoagulation and dual antiplatelet therapy were not associated with loss of graft patency or FTS.

CONCLUSIONS

Failure-to-salvage after femoropopliteal bypass surgery is associated with nonmodifiable factors, and may represent progression of underlying disease. These data may help inform vascular surgeons in counseling patients with failing bypass grafts. Further investigation of care delivery factors improving likelihood of graft salvage may be warranted.

Combined Prognostic Value of Preprocedural Protein-Energy Wasting and Inflammation Status for Amputation and/or Mortality after Lower-Extremity Revascularization in Hemodialysis Patients with Peripheral Arterial Disease

Protein-energy wasting is associated with inflammation and advanced atherosclerosis in hemodialysis patients. We enrolled 800 patients who had undergone successful lower-extremity revascularization, and we investigated the association among the Geriatric Nutritional Risk Index (GNRI) as a surrogate marker of protein-energy wasting, C-reactive protein (CRP), and their joint roles in predicting amputation and mortality. They were divided into lower, middle, and upper tertiles (T1, T2, and T3) according to GNRI and CRP levels, respectively. Regarding the results, the amputation-free survival rates over 8 years were 47.0%, 56.9%, and 69.5% in T1, T2, and T3 of the GNRI and 65.8%, 58.7%, and 33.2% for T1, T2, and T3 of CRP, respectively (p < 0.0001 for both). A reduced GNRI [adjusted hazard ratio (aHR) 1.78, 95% confidence interval (CI) 1.24-2.59, p = 0.0016 for T1 vs. T3] and elevated CRP (aHR 1.86, 95% CI 1.30-2.70, p = 0.0007 for T3 vs. T1) independently predicted amputation and/or mortality. When the two variables were combined, the risk was 3.77-fold higher (95% CI 1.97-7.69, p < 0.0001) in patients who occupied both T1 of the GNRI and T3 of CRP than in those who occupied both T3 of the GNRI and T1 of CRP. In conclusion, patients with preprocedurally decreased GNRI and elevated CRP levels frequently experienced amputation and mortality, and a combination of these two variables could more accurately stratify the risk.

Angiographic and Clinical Impact of Novel Revascularization for Occluded Femoropopliteal Prosthetic Bypass Graft: A Combination of Surgical Thrombectomy and Drug-Coated Balloon Angioplasty

Background

Previous reports have revealed various endovascular intervention techniques for prosthetic femoropopliteal bypass occlusion (PFPBO); however, treatment for PFPBO remains challenging for most interventionalists and vascular surgeons because the procedure is complicated. Most of the reported techniques involve device implantation. In the present study, we performed a combination of surgical graft thrombectomy and drug-coated balloon angioplasty for PFPBO without implanting any additional devices. Furthermore, we determined the favorable long-term results of this treatment using follow-up angiography. Case Presentation. A 77-year-old man with a history of chronic kidney disease and coronary artery disease presented to our clinic with rest pain on his left leg. Seven years prior to the current consult, he underwent femoropopliteal bypass (FPB) surgery using a prosthetic graft due to in-stent occlusion of the left superficial femoral artery (SFA). Four years after surgery, a duplex ultrasound scan revealed stenosis of the proximal anastomosis site; hence, medical therapy was continued. On the current consult, diagnostic angiography revealed occlusion of the FPB and infrapopliteal vessels. In the first attempt at recanalization, the guidewire was unable to pass through the occluded SFA. Therefore, another technique was performed to revascularize the FPBO and infrapopliteal vessels. We obtained an angiography of the left leg after inserting the guiding sheath via the right common femoral artery (CFA). First, surgical thrombectomy using a Fogarty catheter via the exposed left CFA was performed. Following endovascular therapy via the right CFA, we performed drug-coated balloon angioplasty for anastomotic stenosis and recanalized occlusive infrapopliteal vessels. Restenosis was not observed on follow-up angiograms. On further follow-up angiography, there was notable regression of the residual stenosis at the proximal anastomosis of the prosthetic graft.

Conclusion

This novel revascularization strategy may be a viable treatment option for PFPBO.

Characteristics and Outcomes of Patients Undergoing Infrainguinal Bypass in the Endovascular Era

BACKGROUND

The Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) for lower extremity bypass (LEB) in chronic limb-threatening ischemia (CLTI) based on studies that included patients who were at good risk for open revascularization. In the endovascular era, many LEB patients have had prior interventions, and most would be considered high-risk by the original SVS OPG standards. The goal of this study is to characterize a contemporary patient population undergoing LEB for CLTI and determine if outcomes remain commensurate with the parameters established by the SVS OPG.

MATERIALS AND METHODS

All patients who underwent LEB for CLTI over a 10-year period (2012-2021) were identified. Patients were stratified into low- and high-risk categories based upon the clinical, conduit, and anatomic parameters used in the SVS OPG. Limb salvage at 1 year and amputation-free survival, a composite outcome of major amputation and mortality, at 1 year were compared with the SVS OPG cohort. Primary, assisted, and secondary patency at 1 and 3 years were also evaluated using Kaplan-Meier survival analysis.

RESULTS

There were 169 LEBs performed for CLTI. One hundred and two (60.36%) males, 101 (59.76%) current or former smokers, 115 (68.05%) with hypertension, 69 (40.83%) with diabetes mellitus, and 40 (23.67%) with coronary artery disease. Median age was 71.84 years, and mean follow-up was 2.17 years. 65 (38.46%) had a prior ipsilateral endovascular intervention, and 18 (10.65%) were redo bypasses. 21 (12.43%) were deemed clinically high-risk, 44 (26.04%) were high-risk conduits, and 118 (69.82%) had high-risk anatomic factors. Freedom from amputation at 1 year was 87.05% in this cohort which was similar to the overall SVS OPG cohort (88.9%). Amputation-free survival at 1 year was 77.78%, which was also similar to the overall SVS OPG cohort (76.5%). Primary patency at one and three years was 46.84% and 37.59%, assisted patency at one and three years was 61.87% and 44.81%, and secondary patency at one and three years was 72.13% and 61.16%.

CONCLUSIONS

The majority of patients undergoing LEB in the endovascular era meet the SVS OPG criteria for high risk. Despite this, the 1-year limb salvage and amputation-free survival in this cohort were equivalent to the SVS OPG LEB cohort. This supports the continued use of LEB for limb salvage in high-risk patients and those who have failed endovascular approaches.

The value of Wound, Ischemia and foot Infection classification in patients undergoing endovascular therapy

OBJECTIVE

This study aimed to evaluate the correlation between the Society for Vascular Surgery (SVS) Wound, Ischemia and foot infection (WIfI) classification system and clinical outcomes for 1-year limb amputation-free survival (AFS), freedom from reintervention, and wound healing rate in a cohort of patients affected by chronic limb-threatening ischemia treated exclusively by endovascular procedures.

METHODS

We analyzed a prospective, consecutive cohort of 203 patients (203 limbs) who underwent infrainguinal endovascular revascularization at a single center between March 2018 and January 2021. These patients were stratified into clinical stages 1 to 4 based on the SVS WIfI classification and categorized into two groups: WIfI 1 to 3 (n = 101 limbs) and WIfI 4 (n = 102 limbs). The SVS objective performance goals of 1-year limb AFS, freedom from reintervention, and wound healing were compared between the groups and assessed using the Kaplan-Meier method. Angiographic lesion characteristics and angioplasty details were compared.

RESULTS

The average age was 72.4 years (44.3% male, 85.2% had hypertension, 80.3% had diabetes, and 87.7% had tissue loss). There were statistical differences between the groups in 1-year limb AFS Kaplan-Meier rate between WIfI clinical stages 1 to 3 group and WIfI clinical stage 4 group (82% vs 66%, respectively; P < .001), but there was no statistical difference in freedom from reintervention and wound healing rates between the groups (70% vs 64% [P = .62] and 74% vs 79% [P = .90], respectively). Owing to angiographic lesion characteristics, femoropopliteal and infrapopliteal segment distributions were similar between the groups, but there was a statistical difference in target lesion location to tibial vessels (55.4% vs 71.6%, respectively; P = .025).

CONCLUSIONS

In this cohort of patients with chronic limb-threatening ischemia, SVS WIfI clinical stage 4 had worse results in the 1-year limb AFS rate, but there was no statistical difference in freedom from reintervention and wound healing rates between the groups.

Endovascular Popliteal Artery Aneurysm Repair Using an "Off-Label" Abdominal Endograft Limb-Module with Nitinol-Ring Structure: A Single Centre Experience

PURPOSE

To evaluate endovascular popliteal artery aneurysm repair using a an "off-label" abdominal endograft limb-module with nitinol-ring structure.

MATERIALS AND METHODS

Retrospective observational study of 14 popliteal artery aneurysms in 12 male patients (mean age 76 years and median ASA grade 3) treated electively using the Anaconda™ endograft limb (Terumo Aortic) at a single teaching hospital. Eight limbs were treated percutaneously and 6 limbs required surgical arterial exposure. The mean popliteal artery aneurysm diameter treated was 3.6 cm (range 2.1-5.3 cm). Stent-graft diameters and lengths used were 10-15 and 60-140 mm, respectively. The median covered stented length was 218 mm (range 160-270 mm) and median duration of follow-up was 3.7 years. Outcomes assessed included technically successful aneurysm exclusion, primary patency, re-intervention and survival.

RESULTS

All patients had successful stent-graft deployment and aneurysm exclusion, with no early complications or mortality at 30 days. Primary stent-graft patency at 1, 3 and 4 years was 93%, 75%, and 64%. By 8 years, patency had declined with 29% (2/14) stent-grafts patent. 7/14 limbs occluded; 3 underwent re-intervention (2 surgical, 1 endovascular). There were no deaths related to the procedure. Freedom from re-intervention and survival at 1/5 years was 93%/84% and 93%/67%, respectively.

CONCLUSION

The Anaconda™ endograft limb for endovascular popliteal artery aneurysm repair offers good mid-term patency and acceptable long-term patency up to 4 years when compared with other grafts and open surgery. It may be considered in older comorbid patients unfit for surgery and can be performed percutaneously under local anaesthesia when anatomically feasible.

The association of major adverse limb events and combination stent and atherectomy in patients undergoing revascularization for lower extremity peripheral artery disease

BACKGROUND

The effectiveness of combined atherectomy and stenting relative to use of each procedure alone for the treatment of lower extremity peripheral artery disease has not been evaluated.

AIMS

The objective of this study was to evaluate the short- and long-term major adverse limb event (MALE) following the receipt of stenting, atherectomy, and the combination of stent and atherectomy.

METHODS

A retrospective cohort of patients undergoing atherectomy, stent, and combination stent atherectomy for lower extremity peripheral artery disease was derived from the Vascular Quality Initiative (VQI) data set. The primary outcome was MALE and was assessed in the short-term and long-term. Short-term MALE was assessed immediately following the procedure to discharge and estimated using logistic regression. Long-term MALE was assessed after discharge to end of follow-up and estimated using the Fine-Gray subdistribution hazard model.

RESULTS

Among the 46,108 included patients, 6896 (14.95%) underwent atherectomy alone, 35,774 (77.59%) received a stent, and 3438 (7.5%) underwent a combination of stenting and atherectomy. The adjusted model indicated a significantly higher odds of short-term MALE in the atherectomy group (OR = 1.35; 95% confidence interval [CI]:1.16-1.57), and not significantly different odds (OR = 0.93; 95% CI:0.77-1.13) in the combination stent and atherectomy group when compared to stenting alone. With regard to long-term MALE, the model indicated that the likelihood of experiencing the outcome was slightly lower (HR = 0.90; 95% CI:0.82-0.98) in the atherectomy group, and not significantly different (HR = 0.92; 95% CI:0.82-1.04) in the combination stent and atherectomy group when compared to the stent group.

CONCLUSIONS

Patients in the VQI data set who received combination stenting and atherectomy did not experience significantly different rates of MALE when compared with stenting alone. It is crucial to consider and further evaluate the influence of anatomical characteristics on treatment strategies and potential differential effects of comorbidities and other demographic factors on the short and long-term MALE risks.

Objective Performance Goals Based on a Systematic Review and Meta-Analysis of Clinical Outcomes for Bare-Metal Stents and Percutaneous Transluminal Angioplasty for Hemodialysis-Related Central Venous Obstruction

PURPOSE

To use safety and efficacy outcomes following treatment with percutaneous transluminal angioplasty (PTA) and/or stent placement for thoracic central venous obstruction in hemodialysis-dependent patients to establish objective performance goals (OPGs).

METHODS

A systematic literature review and meta-analysis were conducted for articles published between January 1, 2000, and August 31, 2021. Efficacy outcomes included primary patency rates at 6 and 12 months, and safety outcomes included adverse events (AEs) categorized as access loss, procedure-related AEs, and serious AEs (SAEs). OPGs were derived from the upper and lower bounds of the 95% confidence intervals for primary patency and SAE rates.

RESULTS

Of 66 articles reviewed, 17 met the inclusion criteria (PTA, n = 4; stent placement, n = 5; PTA/stent, n = 8). The 6- and 12-month primary patency rates for PTA were 50.9% and 36.7%, respectively. Based on these findings, the proposed 6- and 12-month primary patency OPGs identifying superiority against PTA were 66.5% and 52.6%, respectively, and those for noninferiority were 39.0% and 25.7%, respectively. For stent placement, the 6- and 12-month primary patency rates were 69.7% and 47.9%, respectively. The proposed 6- and 12-month primary patency OPGs identifying superiority were 82.1% and 64.1%, respectively, and those for noninferiority were 59.3% and 35.8%, respectively. SAE rates for PTA and stent placement were 3.8% and 8.1%, respectively. Proposed safety OPGs for noninferiority versus superiority for PTA and stent placement were 10.1% versus 1.4% and 13.6% versus 4.8%, respectively.

CONCLUSION

The OPGs derived from real-world studies of PTA and stent placement may serve as a benchmark for future interventions indicated for this patient population.

Most endovascular thrombectomy patients have Target Mismatch despite absence of formal CT perfusion selection criteria

Endovascular thrombectomy (EVT) is the standard of care for large vessel occlusion stroke. Use of Computed Tomographic Perfusion (CTP) to select EVT candidates is variable. The frequency of treatment and outcome in patients with unfavourable CTP patterns is unknown. A retrospective analysis of CTP utilisation prior to EVT was conducted. All CTP data were analysed centrally and a Target Mismatch was defined as an infarct core ≤70 ml, penumbral volume ≥15ml, and a total hypoperfused volume:core volume ratio >1.8. The primary outcome was good functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score 0-2. follow-up infarct volume, core expansion and penumbral salvage volumes were secondary outcomes. Of 572 anterior circulation EVT patients, CTP source image data required to generate objective maps were available in 170, and a Target Mismatch was present in 151 (89%). The rate of 90-day good functional outcome was similar between Target Mismatch (53%) and Large Core Non-Mismatch groups (46%, p = 0.629). Median follow-up infarct volume in the Large Core Non-Mismatch group (104ml [IQR 25ml-189ml]) was larger than that in the Target Mismatch patients (16ml [8ml-47ml], p<0.001). Despite a lack of formal CTP selection criteria, the majority of patients treated at our centres had a Target Mismatch. Patients without Target Mismatch had larger follow-up infarct volumes, but the functional recovery rate was similar to that in Target Mismatch patients. Infarct volumes should be included as objective assessment criteria in the evaluation of the efficacy of EVT in non-Target Mismatch patients.

Impact of cilostazol on prevention of late failure of autologous vein grafts

OBJECTIVES

The effectiveness of postoperative medication for the prevention of late graft failure is controversial. We conducted the present study to investigate whether cilostazol improved the mid-term outcomes after infrainguinal autologous vein bypass for chronic limb-threatening ischemia (CLTI).

METHODS

From April 1994 to March 2022, we performed 590 de novo infrainguinal bypass procedures using autologous vein grafts (AVGs) in three hospitals. The bypass grafts were classified according to the postoperative prescription of cilostazol. The loss of graft patency and major adverse limb events (MALEs) were set as endpoints. Patients who died within 30 days and grafts that lost primary patency within 30 days after surgery were excluded. Data up to 3 years were analyzed. The cumulative primary patency (PP), assisted primary patency (AP), secondary patency (SP), and freedom from MALE (ffMALE) rates were calculated by the Kaplan-Meier method and compared between the cilostazol group and the non-cilostazol group. After a propensity score matching, same statistical analyses were performed. In addition, a Cox proportional hazards regression analysis that included preoperative factors, intraoperative factors, and postoperative medications was performed to identify whether cilostazol is an independent predictor for the outcomes.

RESULTS

A total of 523 AVGs met inclusion criteria. Kaplan-Meier curves showed that the cilostazol group was superior to the non-cilostazol group in all outcomes, while the cilostazol group was superior to the non-cilostazol group in AP and SP after a propensity score matching. A multivariable analysis showed that non-use of cilostazol was identified as an independent predictor for loss of AP, SP, and ffMALE.

CONCLUSIONS

Cilostazol improved the mid-term outcomes after infrainguinal autologous vein bypass.

Clinical outcomes of chronic limb-threatening ischemia due to inflammatory nonatherosclerotic versus atherosclerotic etiologies undergoing revascularization

BACKGROUND

The scope of clinical guidelines for the management of chronic limb-threatening ischemia (CLTI) is limited to atherosclerotic disease of the lower-extremity arteries. This study aimed to reveal the clinical features and prognoses of CLTI due to inflammatory nonatherosclerotic etiologies undergoing revascularization.

METHODS

DECOPON (DatabasE of ChrOnic limb-threatening ischemia Presenting ischemic ulcer and gangrene due to nON-atherosclerotic disease) is a multicenter retrospective study that evaluated 465 limbs of 414 patients with CLTI undergoing revascularization for ischemic tissue loss with inflammatory nonatherosclerotic etiologies between 2010 and 2020. Clinical features and prognoses were compared with 930 limbs of 809 patients with atherosclerotic CLTI during the same period.

RESULTS

The frequency of conventional atherosclerotic risk factors was significantly lower in the inflammatory nonatherosclerotic group. The inflammatory nonatherosclerotic group had more severe WIfI (wound, ischemia, and foot infection) W and fI grades, and more frequent infrapopliteal and inframalleolar artery diseases with a rarer presence of arterial calcification (all p < 0.05). Adjunctive therapy was more frequently performed in the inflammatory nonatherosclerotic group (p < 0.05). The inflammatory nonatherosclerotic group had a lower incidence rate of wound healing (0.64-fold, p < 0.001) and a higher incidence rate of major reintervention (2.30-fold, p = 0.006), whereas the risk ratio of all-cause mortality was 0.83-fold (p = 0.067). The association of inflammatory nonatherosclerotic disease with the delayed wound healing and the susceptibility to major reintervention remained significant even after adjustment for covariates (both p < 0.001).

CONCLUSIONS

Patient, limb, and lesion characteristics of inflammatory nonatherosclerotic CLTI were considerably different from those of atherosclerotic CLTI. Inflammatory nonatherosclerotic CLTI was less likely to heal than atherosclerotic CLTI.

Association between sex and long-term outcomes of endovascular treatment for peripheral artery disease

BACKGROUND

Endovascular peripheral vascular intervention (PVI) has become the primary revascularization technique used for peripheral artery disease (PAD). Yet, there is limited understanding of long-term outcomes of PVI among women versus men. In this study, our objective was to investigate sex differences in the long-term outcomes of patients undergoing PVI.

METHODS

We performed a cohort study of patients undergoing PVI for PAD from January 1, 2010 to September 30, 2015 using data in the Vascular Quality Initiative (VQI) registry. Patients were linked to fee-for-service Medicare claims to identify late outcomes including major amputation, reintervention, major adverse limb event (major amputation or reintervention [MALE]), and mortality. Sex differences in outcomes were evaluated using cumulative incidence curves, Gray's test, and mixed effects Cox proportional hazards regression accounting for patient and lesion characteristics using inverse probability weighted estimates.

RESULTS

In this cohort of 15,437 patients, 44% (n = 6731) were women. Women were less likely to present with claudication than men (45% vs. 49%, p < 0.001, absolute standardized difference, d = 0.08) or be able to ambulate independently (ambulatory: 70% vs. 76%, p < 0.001, d = 0.14). There were no major sex differences in lesion characteristics, except for an increased frequency of tibial artery treatment in men (23% vs. 18% in women, p < 0.001, d = 0.12). Among patients with claudication, women had a higher risk-adjusted rate of major amputation (hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.18-2.49), but a lower risk of mortality (HR = 0.86, 95% CI: 0.75-0.99). There were no sex differences in reintervention or MALE for patients with claudication. However, among patients with chronic limb-threatening ischemia, women had a lower risk-adjusted hazard of major amputation (HR = 0.79, 95% CI: 0.67-0.93), MALE (HR = 0.86, 95% CI: 0.78-0.96), and mortality (HR = 0.86, 95% CI: 0.79-0.94).

CONCLUSION

There is significant heterogeneity in PVI outcomes among men and women, especially after stratifying by symptom severity. A lower overall mortality in women with claudication was accompanied by a higher risk of major amputation. Men with chronic limb-threatening ischemia had a higher risk of major amputation, MALE, and mortality. Developing sex-specific approaches to PVI that prioritizes limb outcomes in women can improve the quality of vascular care for men and women.

Racial and ethnic disparities in major adverse limb events persist for chronic limb threatening ischemia despite presenting limb threat severity after peripheral vascular intervention

OBJECTIVE

Racial and ethnic disparities have been well-documented in the outcomes for chronic limb threatening ischemia (CLTI). One purported explanation has been the disease severity at presentation. We hypothesized that the disparities in major adverse limb events (MALE) after peripheral vascular intervention (PVI) for CLTI would persist despite controlling for disease severity at presentation using the WIfI (Wound, Ischemia, foot Infection) stage.

METHODS

The Vascular Quality Initiative PVI dataset (2016-2021) was queried for CLTI. Patients were excluded if they were missing the WIfI stage. The primary end point was the incidence of 1-year MALE, defined as major amputation (through the tibia or fibula or more proximally) or reintervention (endovascular or surgical) of the initial treatment limb. A multivariate hierarchical Fine-Gray analysis was performed, controlling for hospital variation, competing risk of death, and presenting WIfI stage, to assess the independent association of Black/African American race and Latinx/Hispanic ethnicity with MALE. A Cox proportional hazard regression model was used for the 1-year survival analysis.

RESULTS

Overall, 47,830 patients (60%) had had WIfI scores reported (73% White, 20% Black, and 7% Latinx). The 1-year unadjusted cumulative incidence of MALE was 13.1% (95% confidence interval [CI], 12.6%-13.5%) for White, 14.3% (95% CI, 13.5%-15.3%) for Black, and 17.0% (95% CI, 15.3%-18.9%) for Latinx patients. On bivariate analysis, the occurrence of MALE was significantly associated with younger age, Black race, Latinx ethnicity, coronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, diabetes, dialysis, intervention level, any prior minor or major amputation, and WIfI stage (P < .001). The cumulative incidence of 1-year MALE increased by increasing WIfI stage: stage 1, 11.7% (95% CI, 10.9%-12.4%); stage 2, 12.4% (95% CI, 11.8%-13.0%); stage 3, 14.8% (95% CI, 13.8%-15.8%); and stage 4, 15.4% (95% CI, 14.3%-16.6%). The cumulative incidence also increased by intervention level: inflow, 10.7% (95% CI, 9.8%-11.7%), femoropopliteal, 12.3% (95% CI, 11.7%-12.9%); and infrapopliteal, 14.1% (95% CI, 13.5%-14.8%). After adjustment for WIfI stage only, Black race (subdistribution hazard ratio [SHR], 1.30; 95% CI, 1.17-1.44; P < .001) and Latinx ethnicity (SHR, 1.58; 95% CI, 1.37-1.81; P < .001) were associated with an increased 1-year hazard of MALE compared with White race. On adjusted multivariable analysis, MALE disparities persisted for Black/African American race (SHR, 1.12; 95% CI, 1.01-1.25; P = .028) and Latinx/Hispanic ethnicity (SHR, 1.34; 95% CI, 1.16-1.54; P < .001) compared with White race.

CONCLUSIONS

Black/African American and Latinx/Hispanic patients had a higher associated hazard of MALE after PVI for CLTI compared with White patients despite an adjustment for WIfI stage at presentation. These results suggest that disease severity at presentation does not account for disparities in outcomes. Further work should focus on better understanding the underlying mechanisms for disparities in historically marginalized racial and ethnic groups presenting with CLTI.

Frailty in People with Chronic Limb Threatening Ischemia and Diabetes-Related Foot Ulcers: A Systematic Review

BACKGROUND

Frailty represents a state of multisystem impairment that may adversely impact people presenting with chronic limb-threatening ischemia (CLTI) and diabetes-related foot ulcers (DFUs). The aim of this systematic review was to explore the association between frailty and outcomes from CLTI and DFUs.

METHODS

We performed a systematic literature search of electronic databases to find studies using a validated measure of frailty in individuals with CLTI and/or DFUs. The primary outcomes were the impact of frailty on the severity of initial clinical presentation and unfavorable follow-up outcomes including readmissions, major limb amputation, cardiovascular events, revascularization, and wound healing.

RESULTS

Ten cohort studies were included. Two studies had a low risk of bias, 1 was unable to be assessed, 5 had moderate risk of bias, and 2 high risk of bias. The prevalence of frailty in people presenting with CLTI ranged from 27% to 88% and was 71% in people with DFUs. The presence of frailty in both people with CLTI and DFUs was associated with substantially increased severity at presentation (severity of ischemia and tissue loss) and poorer outcomes at follow-up (risk of readmission, limb amputation, and all-cause mortality).

CONCLUSIONS

The presence of frailty in both people with CLTI and DFUs is likely associated with substantially higher complexity at presentation followed by a greater risk for readmission, amputation, and death during follow-up. Heterogeneity in the tools used to screen for frailty, poor definition of frailty, and unclear evaluation of exposure and outcomes limit further interpretation of findings.

Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia

INTRODUCTION

The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI).

METHODS

We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers. WIfI stages and grades were determined for each patient. Toe, ankle, and brachial pressure measurements were performed by registered vascular technologists. CLTI severity was characterized using Global Limb Anatomic Staging System (GLASS stages) and angiosomes. Medial artery calcification in the foot was quantified on foot radiographs.

RESULTS

GLASS NA (not applicable), I, II, and III angiographic findings were seen in 21, 21, 23, and 35 patients, respectively. A toe-brachial index < 0.7 and minimum ipsilateral ankle-brachial index < 0.9 performed well in identifying GLASS II and III angiographic findings, with sensitivity rates 97.8% and 91.5%, respectively. The diagnostic accuracy rates of noninvasive measures peaked at 74.7% and 89.3% for identifying GLASS II/III and GLASS I+ angiographic findings, respectively. The presence of medial artery calcification significantly diminished the sensitivity of most noninvasive parameters.

CONCLUSIONS

The use of alternative noninvasive arterial testing parameters improves sensitivity for detecting PAD. Abnormal noninvasive results should suggest the need for diagnostic angiography to further characterize arterial anatomy of the affected limb. Testing strategies with better accuracy are needed.

Outcomes and Patency of Endovascular Infrapopliteal Reinterventions in Patients With Chronic Limb-Threatening Ischemia

PURPOSE

Endovascular revascularization is the preferred treatment to improve perfusion of the lower extremity in patients with chronic limb-threatening ischemia (CLTI). Patients with CLTI often present with stenotic-occlusive lesions involving the infrapopliteal arteries. Although the frequency of treating infrapopliteal lesions is increasing, the reintervention rates remain high. This study aimed to determine the outcomes and patency of infrapopliteal endovascular reinterventions.

METHODS

This retrospective, multicenter cohort study of 3 Dutch hospitals included patients who underwent an endovascular infrapopliteal reintervention in 2015 up to 2021 after a primary infrapopliteal intervention for CLTI. The outcome measures after the reintervention procedures included technical success rate, the mortality rate and complication rate (any deviation from the normal postinterventional course) at 30 days, overall survival, amputation-free survival (AFS), freedom from major amputation, major adverse limb event (MALE), and recurrent reinterventions (a reintervention following the infrapopliteal reintervention). Cox proportional hazard models were used to determine risk factors for AFS and freedom from major amputation or recurrent reintervention.

RESULTS

Eighty-one patients with CLTI were included. A total of 87 limbs underwent an infrapopliteal reintervention in which 122 lesions were treated. Technical success was achieved in 99 lesions (81%). The 30-day mortality rate was 1%, and the complication rate was 13%. Overall survival and AFS at 1 year were 69% (95% confidence interval [CI], 55%-79%) and 54% (95% CI, 37%-67%), respectively, and those at 2.5 years were 45% (95% CI, 33%-56%) and 21% (95% CI, 11%-33%), respectively. Freedom from major amputation, MALE, and recurrent reinterventions at 1 year and 2.5 years were 59% (95% CI, 46%-70%) and 41% (95% CI, 25%-56%); 54% (95% CI, 41%-65%) and 36% (95% CI, 21%-51%); and 68% (95% CI, 55%-78%) and 51% (95% CI, 33%-66%), respectively. A Global Limb Anatomic Staging System score of III showed an increased hazard ratio of 2.559 (95% CI, 1.078-6.072; p=0.033) for freedom of major amputation or recurrent reintervention.

CONCLUSIONS

The results of this study indicate that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, outcomes and patency were moderate to poor, with low AFS, high rates of major amputations, and recurrent reinterventions.

CLINICAL IMPACT

This multicenter retrospective study evaluating outcome and patency of endovascular infrapopliteal reinterventions for CLTI, shows that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, the short- and mid-term outcomes of the infrapopliteal reinterventions were moderate to poor, with low rates of AFS and a high need for recurrent reinterventions. While the frequency of performing infrapopliteal reinterventions is increasing with additional growing complexity of the disease, alternative treatment options such as venous bypass grafting or deep venous arterialization may be considered and should be studied in randomized controlled trials.

Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia

BACKGROUND

Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes.

METHODS

In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event - which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) - or death from any cause.

RESULTS

In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts.

CONCLUSIONS

Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar. (Funded by the National Heart, Lung, and Blood Institute; BEST-CLI ClinicalTrials.gov number, NCT02060630.).

Long-Term Outcomes following Common Femoral Endarterectomy

Thromboendarterectomy of the common femoral artery (CFA) for occlusive disease is a crucial procedure in vascular surgery. As an outcome reference for emerging endovascular procedures and new devices, we need more robust evidence of the outcome of this gold standard technique. The purpose of this study was to report 10-year results after femoral endarterectomy (FEA). A retrospective review of medical records at our institution identified eighty consecutive patients (91 limbs) who underwent FEA for CFA lesions. Indications for FEA included 50 limbs (55%) for intermittent claudication (IC) and 39 limbs (43%) with chronic limb-threatening ischemia (CLTI). Two limbs (2%) underwent FEA to prevent hemodynamic steal during extra-anatomical bypass. Adjunctive procedures included endovascular therapy in 32%. CFAs were closed with patch angioplasty in 44%. With a mean follow-up period of 39 months, the survival rates at 3 and 8 years were 85% and 77%, respectively. Limb salvage rates were 92% and 87%. Primary patencies were 98% and 84%. Freedom from target lesion revascularization was 95% at 3 years and 91% at 8 years. Our findings support the durability of FEA, with comparable long-term procedural results in CLTI patients as well as IC patients. Since the FEA is a gate maneuver for hybrid revascularization in CLTI patients, our findings support a strategy combining open and endovascular approaches. Femoral endarterectomy remains a durable solution for common femoral occlusive disease in IC and CLTI in the era of endovascular therapy.

Temsirolimus Adventitial Delivery to Improve ANGiographic Outcomes Below the Knee

BACKGROUND

Current endovascular treatments of below the knee (BTK) popliteal or tibial/peroneal arteries including investigational drug-coated balloons have limited long-term efficacy.

OBJECTIVES

This Phase 2 trial assessed the feasibility of adventitial deposition of temsirolimus to reduce neointimal hyperplasia and clinically relevant target lesion failure (CR-TLF) 6 months after BTK arterial revascularization.

METHODS

This prospective, multicenter, double-blinded, comparative, dose-escalation trial enrolled 61 patients with Rutherford 3 to 5 symptoms undergoing endovascular revascularization of ≥1 angiographically significant BTK lesions. Perivascular infusion after completion of arterial revascularization was randomized into control (saline) vs low-dose (0.1 mg/mL) temsirolimus groups for the first 30 patients. In the second part of the trial, patients were randomized to control versus high-dose (0.4 mg/mL) temsirolimus groups. Primary and secondary efficacy endpoints were target lesion (TL) transverse-view vessel area loss percentage (TVAL%) and CR-TLF at 6 months, respectively. CR-TLF was defined as a composite of ischemia-driven major amputation of the target limb, clinically driven target lesion revascularization (CD-TLR), and clinically relevant TL occlusion. The primary safety endpoint was freedom from major adverse limb events or perioperative death (MALE+POD) at 30 days.

RESULTS

There was no discernable difference in effect between temsirolimus doses; therefore, the low- and high-dose cohorts were pooled for the analyses. The principal analysis on the per protocol (PP) group of 53 patients revealed superior primary efficacy of the treatment arm, with reduction in TVAL% of 13.9% absolute (37.3% relative) and the rate of CR-TLF reduced by 27.1% absolute (51.3% relative), at 6 months. Subgroup analysis of all Trans-Atlantic Inter-Society Consensus (TASC) B to D lesions (N=36) revealed TVAL% reduction of 22.3% absolute (48.3% relative) and the rate of CR-TLF reduced by 39.2% absolute (56.6% relative). Freedom from 30-day MALE+POD was 100% in all groups.

CONCLUSIONS

This hypothesis-generating trial suggests that adventitial infusion of temsirolimus in BTK arteries improves TVAL% and CR-TLF with no adverse safety signals through 6 months, supporting the move to a Phase 3 trial.

CLINICAL IMPACT

There remain gaps in the endovascular treatment of patients with atherosclerotic lesions of below-the-knee (BTK) arteries. The TANGO trial evaluated the use of sub-adventitial temsirolimus with the Bullfrog micro-infusion device during BTK interventions. The therapy was safe and effective. Compared with controls, vessel lumen area patency was improved, and target lesion failure was less frequent. The effects were most appreciable in subjects with higher baseline TASC lesions (B, C, or D). Sub-adventitial temsirolimus offers the potential to improve the results of BTK interventions in this challenging patient population.

Impact of Guideline-Directed Medical Therapy on 10-Year Mortality after Revascularization for Patients with Chronic Limb-Threatening Ischemia

AIMS

This study aimed to investigate the long-term impact of guideline-directed medical therapy (GDMT) on 10-year mortality in patients with chronic limb-threatening ischaemia (CLTI) after revascularization.

METHODS

We performed a retrospective multicentre study enrolle 459 patients with CLTI who underwent revascularization (396 endovascular therapy [EVT] and 63 bypass surgery [BSX] cases) between January 2007 and December 2011. The primary outcome measure was all-cause mortality. We additionally explored the predictors for all-cause mortality using Cox regression hazard models; the influence of GDMT, defined as prescription of antiplatelet agents, statins, and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in aggregate, on all-cause mortality, and the association between baseline characteristics using interaction effects.

RESULTS

During the 10-year follow-up after revascularization, 234 patients died. In Kaplan-Meier analysis, 10-year mortality was significantly lower in patients who received statins (p＜.001) and ACE inhibitors or ARBs (p=.010) than those who did not. However, there were no differences in 10-year mortality between patients who received anti-platelet agents and those who did not (p=.62). Interaction analysis revealed that GDMT had a significantly different hazard ratio in patients who were and were not on hemodialysis and in those treated with EVT or BSX (p for interaction =.002 and .044, respectively). In the multivariate analysis, age ＞75 years, non-ambulatory status, hemodialysis, congestive heart failure, left ventricular ejection fraction ＜50%, and GDMT were significantly associated with all-cause mortality.

CONCLUSIONS

Appropriate GDMT use was independently associated with 10-year mortality in patients with CLTI after revascularization.

Creation of objective performance criteria among medical devices

Objectives

Objective performance criteria (OPC) may serve as a tool to expedite the approval process and continue active surveillance of class III medical devices. Thus far, published guidance on the creation of OPC has been clinical area-specific. This study aimed to capture reflections from key stakeholders on the creation of OPC that may serve as a precursor for a formalized conceptual framework within the USA.

Design

Reflections from key stakeholders and guidance from an advisory committee were captured to gain an understanding of the elements that are crucial to the generation of OPC.

Setting

A non-probability sampling method using the purposive sampling strategy was employed to identify relevant stakeholders for engagement in semi-structured, open-ended, concept elicitation discussions.

Participants

Stakeholders involved in the generation of OPC.

Main outcome measures

Elements and themes regarding the priorities of, experiences with, roles within and perceived challenges associated with OPC creation captured through a phenomenological approach.

Results

A total of 27 participants were engaged to represent the following contributors: representatives of registries, health systems, health technology assessment bodies, clinicians, device application reviewers, payers, patients, patient representatives, patient caregivers, device manufacturers, data coordinators, data analysts and data informaticians. Consensus was achieved on the five core elements: (1) identification of medical devices, (2) engagement of key stakeholders, (3) selection of data source, (4) performance of appropriate statistical analyses and (5) reporting of findings. The engagement of key stakeholders (38%) was cited most frequently as the most important core element. Access to meaningful and high-quality data sources (47%) was the most frequently mentioned challenge.

Conclusions

The reflections from the participants identified five elements to be considered when generating an OPC within class III medical devices and may provide the needed foundation for the development of official guidance on OPC generation.

Early Experience with Venous Arterialization for Limb Salvage in No-Option Patients with Chronic Limb-Threatening Ischemia

OBJECTIVES

Chronic limb-threatening ischemia (CLTI) is associated with adverse limb outcomes and increased mortality. In a small subset of the CLTI population, there are no feasible conventional means of revascularization. In such cases, venous arterialization (VA) provides an alternative for limb salvage. The objective of this study was to review the outcomes of venous arterialization (VA) at our institution.

METHODS

This is a single institution review of 41 patients followed prospectively who underwent either superficial or deep VA. Data collected included: patient demographics, co-morbidities, VA technique (endovascular vs. hybrid) and WIfI (wound ischemia foot infection) limb staging. Data were collected at 1 month, 6 months and 1-year intervals and included the following outcomes: patency, wound healing, major adverse limb event (MALE), major amputation and death. Descriptive statistics were used for analysis.

RESULTS

The study group includes 41 patients who underwent successful open hybrid superficial or deep endovascular VA; 21 (51.2%) underwent a purely endovascular procedure and 20 (48.8%) had hybrid VA. The WIfI clinical stages were as follows: 33 (80.5%) stage 4, 6 (14.6%) stage 3, and 1 (2.4%) stage 2. Twenty-four (58.5%) patients completed follow-up at 6 months and 16 (39%) at 1 year. VA primary patency at 12 months was 28.6% (95% CI 0.15-0.43), primary assisted patency at 12 months was 44.3% (95% CI 0.27-0.60) and secondary patency at 12 months was 67% (95% CI 0.49-0.80). Complete wound healing rates were 2.7% (1) at 1 month; 62.5% (15) at 6 months; and 18.8% (3) at 1 year. Overall wound healing at 1 year was 46.3% (19). MALE rate at 1 year was 36.5% (15) comprised of 19.5% (8) re-interventions and 17% (7) major amputations. There were 0 (0%) deaths at 1 month and 4 (19%) deaths at 6 months; 2 (9.5%) deaths were attributed to COVID-19. There were no further deaths within 1 year. The limb salvage survival probability at 1 year was 81%.

CONCLUSIONS

These findings suggest that for a select subset of CLTI patients presenting with high WIfI clinical limb stage CLTI and no viable options for conventional open or endovascular arterial revascularization, superficial and deep venous arterialization are feasible options to achieve limb salvage.

Limb-based patency as a measure of effective revascularization for chronic limb-threatening ischemia

OBJECTIVE

In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway (TAP) following intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events following infrainguinal revascularization for CLTI.

METHODS

Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aorto-iliac disease, prior infrainguinal stents or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System (GLASS) scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of re-intervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. Major adverse limb events (MALE) included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation.

RESULTS

184 unique limbs in 163 patients were analyzed. This cohort was composed of 66.9% male patients with a mean age of 72. Baseline characteristics included diabetes (66%), tissue loss (91%) and advanced WIfI stages (30% stage 3, 51% stage 4). GLASS stage 3 anatomic patterns were common (n=119; 65%). 60 limbs were treated with open bypass (65% involving tibial targets) while 124 underwent endovascular intervention (70% including infrapopliteal targets). 12-month freedom from MALE and loss of LBP were 74.0%±3.7% and 48.6%±4.2%, respectively. Diabetes (HR=2.56 [1.13-5.83]; p=.025) and loss of LBP (4.12 [1.96-8.64]; p<.001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR=4.97 [1.89-13.09]; p=.001). Loss of LBP impacted both intermediate-risk limbs (HR=2.85 [1.02-7.97]; p=.047 in WIfI stages 1-3) and high-risk limbs (HR=3.99 [1.32-12.11]; p=.014 in WIfI stage 4). However, loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs. 8% major limb amputation at 12-months in limbs without vs. with maintained LBP).

CONCLUSIONS

Anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4).